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7.3 Supplementation

Exclusive breastfeeding

Baby Friendly Point 5 and Step 6

Step 6 of the Ten Steps to Successful Breastfeeding, and Point 5 of the Seven-point Plan for Sustaining Breastfeeding in the Community state:
Step 6: Give newborn infants no food or drink other than breastmilk, unless medically indicated.
Point 5: Encourage exclusive and continued breastfeeding (beyond six months) (to two years or more), with appropriately-timed introduction of (adequate and safe) complementary foods.

Pre-lacteal feeds

Pre-lacteal feeds are any feeds given to the newborn before breastfeeding is established and the milk 'comes in', often within 0-2 hrs of birth. Honey, teas, pastes and herbal preparations are cultural and religious choices.1 Water, glucose water, milk-based substitutes are common pre-lacteal feeds given in hospital.2 3

Prelacteal feeds have been given in some cultures since ancient times in the belief that colostrum is harmful to infant, stale, and that it is not considered to be 'true breastmilk'.4 Colostrum may be expressed and discarded or replaced with the prelacteals.5 The prelacteals are believed to moisten the mouth and cleanse the gastrointestinal tract and aid expulsion of the meconium.4

Effect on mother and infant

Colostrum is essential for gut protection, growth and repair as well as the establishment of the bifidobacterium environment. Colostrum aids the expulsion of meconium which reduces enterohepatic circulation of bilirubin. Prelacteal feeding impairs these processes. Water provides no nutrition and fills the infant's stomach lessening the urge to breastfeed. As a result, breastmilk intake is minimal ...
  • increasing diarrhea and infections,6
  • increasing breastfeeding problems,7
  • decreases exclusive breastfeeding and duration of breastfeeding,7,6,8,3 and
  • the cycle of delayed initiation of lactation has the propensity to cause further use of prelacteal feedings.9

The practice of giving pre-lacteal feeds is a key determinant of early cessation of full breastfeeding.3With education and support for breastfeeding, the acceptance of exclusive breastfeeding from birth has become more widespread.

Supplementation

Even more common than giving pre-lacteal feeds has been the routine giving of post-breastfeed supplements, or additional bottles of water, glucose water or artificial infant milk.

The reasons sometimes given for this practice include:

  • to give the mother a rest
  • because the mother doesn't have her milk 'in' yet
  • to calm a crying infant
  • to prevent hypoglycemia
  • to prevent or reduce jaundice

None of these reasons are indications for giving supplements, with some having the opposite effect to the result desired.

Medical indications for supplementation

The World Health Organization states that there are few medical indications that may require individual infants to be given fluids or food in addition to, or in place of, breastmilk. Whenever stopping breastfeeding is considered, the risks of infant formula feeding and the benefits of breastfeeding should be weighed against the risks posed by the presence of the specific condition listed. The following circumstances may be considered:

Infant conditions:

  • These infants should receive only specialized infant formula:
    • an infant with certain inborn errors of metabolism; eg classic galactosemia, maple syrup urine disease, phenyloketonuria (some breastfeeding possible with careful monitoring)
  • These infants should continue to receive breastmilk, but may require other food in addition for a limited time:
    • infants with very low birth weight (<1500g) or who are born preterm (before 32 weeks gestational age)
    • infants with potentially severe hypoglycemia, or who require therapy for hypoglycemia, and who do not improve through increased breastfeeding or by being given breastmilk.

Maternal conditions:

  • HIV infection. Individualized assessment required that includes the availability of counseling and support, and that infant formula feeding will be acceptable, feasible, affordable, sustainable and safe (AFASS). Antiretroviral therapy and exclusive breastfeeding for 6 months must be supported if the mother breastfeeds.
  • Temporary infant formula feeding may be necessary when
    • the mother is taking medication which is contraindicated when breastfeeding, and for which there is no safe alternative. Rarely are there no safe alternatives, however cytotoxic chemotherapy is one.
    • the mother abuses drugs such as heroin, cocaine, amphetamines, cannabis, alcohol etc. Seek individual counseling for mothers in these instances to assess their dependency and the needs of their infant.

Adapted from WHO/UNICEF: Baby-Friendly Hospital Initiative. Hospital level Implementation 1992.

Protect breastfeeding

While breastfeeding is temporarily delayed or interrupted for any reason, the mother should be given instructions to maintain her milk supply (or increase it as the case may be) by regular expression of milk.
Encourage the mother to be with her baby as much as possible. Explain to her about the importance of her breastmilk for her baby and discuss strategies for the infant's return to breastfeeding.

Review the literature which you can give to the mother about expressing, storage of breastmilk and maintaining milk supply.

Supplements in order of preference

When the baby cannot be breastfed, the World Health Organisation sets a feeding preference in this order:10
  • The mother's own expressed breastmilk
  • Donor breastmilk - from another healthy mother or human milk bank
  • Infant formula. The type chosen requires careful consideration of maternal preference and family history of allergies. A pediatrician should guide the choice according to infant need.
The WHO strategy states that infants who are not breastfed should receive special attention from health systems as they constitute a group at risk for growth and health problems.

Effect on infant health

As mentioned earlier, prelacteal feeds and supplements change the normal flora of the intestine, decreases gut mobility, increases jaundice, etc. Artificial infant milk can be contaminated during manufacture and preparation, and the feeding implements can introduce another source of infection. Protective properties such as lactoferrin are inactivated by artificial infant milk.11

Effect on breastfeeding

As with pre-lacteal feeds, researchers using randomized, controlled trials and prospective studies found the use of supplements during the hospital stay (and afterwards) is associated with

earlier cessation of exclusive breastfeeding and earlier weaning.

Breastfeeding is negatively affected when formula is used, even in hospitals where educational materials, counseling, support and policies are generally favorable to breastfeeding. Research was conducted in a unit where nursing staff's attitudes regarding breastfeeding were very positive with more than 80% reporting discussing the advantages of breastfeeding routinely with mothers.12 However, 77% of mothers had started bottle-feeding 2 to 3 weeks after birth, the majority (93%) remembered which brand of formula was used to supplement their baby in hospital and most were using that brand.

Parents may interpret the use of formula as an endorsement by hospital staff, despite clear verbal messages promoting breastfeeding.

Effect on the mother

The reduced breast stimulation and reduced milk removal that occurs as a result of the infant being given supplements results in

  • an increased incidence of breast engorgement, and
  • more severe engorgement, which can cause breast involution and the failure of adequate lactation. Early, frequent milk removal is pivotal to the success of breastfeeding in the coming weeks.
  • shorter duration of lactational amenorrhoea13
Giving supplements when a medical indication does not exist causes a loss of maternal self-confidence.14

Effect on infant serum glucose levels

Serum glucose levels normally drop to their lowest levels at about 2 hours of age, then rise to remain normal for up to 24 hours, irrespective of feeding.15 Giving babies glucose water or artificial infant formula only serves to interfere with this normal physiological process and is poor clinical practice.

Effect on hyperbilirubinemia

Likewise the pathophysiology of hyperbilirubinemia does NOT respond to giving water. Reduced breastfeeding frequency and supplementation with water or glucose water have been associated with increased serum bilirubin concentrations in the first 5 days of life.16 Lack of early feeding delays passage of meconium and increases enterohepatic re-absorption of bilirubin.

Increased breastfeeding is the best way to treat the additional insensible water loss that is caused when phototherapy is instituted.17

Effect on atopic disease

Even just one or two artificial baby milk feeds at this time may result in the development of cow's milk intolerance or cow's milk allergy, which will become symptomatic later in infancy.18,19

Effect on infant digestion and absorption

Artificial infant formula is poorly digested and absorbed compared to breastmilk as

  • there is a normal immaturity of digestion and absorption at birth
  • breastmilk contains enzymes to aid digestion (eg lipase)
  • breastmilk macronutrients are in easily digested form
  • absorption of minerals is enhanced by breastmilk 'transporters'

Let's solve this problem...

Lack of understanding of normal newborn behavior and maternal fatigue appear to be the major reasons mothers give their infants supplements. Time for some brainstorming!

Brainstorm with your colleagues ways of supporting a tired mother in hospital who has requested a supplement, or who, in the community setting, is wanting to give supplements to change her baby's behavior.

Human Immunodeficiency Virus (HIV)

  • Exclusive breastfeeding, combined with antiretroviral therapy has a low risk of mother-to-child transfer of HIV. 20 21 22
  • Mixed feeding (ie breastfeeding and giving supplements) significantly increases the risk of mother-to-child (MTC) transfer of HIV.

Exposure to cow's milk protein and other foods damages the permeable infant gut allowing transfer of the HIV virus. 23 Unless it is known, without doubt, that a mother is HIV negative then there is a likelihood the baby may suffer serious morbidity and eventual mortality from giving a breastfed infant just one supplementary bottle.

Workbook Activity 7.6

Complete Activity 7.6 in your workbook.

Unit Activity

Review your Unit's policy on supplementation AND common practices of the staff. Ensure that there are very clear policy guidelines for when a supplement is medically indicated. Discuss with your colleagues the implications for them, the mother and the baby should they not follow this policy.

Do you have an "Informed Consent" form to ensure mothers are aware of the dangers of infant formula?

What should I remember?

  • Exclusive breastfeeding, initiated immediately after birth provides the best opportunity for optimal health.
  • Any food or liquid other than breastmilk is foreign and harmful to an infant and breastfeeding.
  • The effects of pre-lacteals and supplementation on the infant, mother and breastfeeding.

Self-test quiz

Notes

  1. # Laroia N et al. (2006) The religious and cultural bases for breastfeeding practices among the Hindus.
  2. # Akuse RM et al. (2002) Why healthcare workers give prelacteal feeds.
  3. # Lakati AS et al. (2010) The effect of pre-lacteal feeding on full breastfeeding in Nairobi, Kenya.
  4. # Ingram J et al. (2003) South Asian grandmothers' influence on breast feeding in Bristol.
  5. # Rogers NL et al. (2011) Colostrum avoidance, prelacteal feeding and late breast-feeding initiation in rural Northern Ethiopia.
  6. # Hossain MM et al. (1992) Prelacteal infant feeding practices in rural Egypt.
  7. # Isenalumhe AE et al. (1987) Prelacteal feeds and breast-feeding problems.
  8. # Pérez-Escamilla R et al. (1996) Prelacteal feeds are negatively associated with breast-feeding outcomes in Honduras.
  9. # Ahmed FU et al. (1996) Prelacteal feeding: influencing factors and relation to establishment of lactation.
  10. # World Health Organisation (2003) Global Strategy for Infant and Young Child feeding
  11. # Wharton BA et al. (1994) Faecal flora in the newborn. Effect of lactoferrin and related nutrients
  12. # Reiff MI et al. (1985) Hospital influences on early infant-feeding practices.
  13. # McNeilly AS (2001) Neuroendocrine changes and fertility in breast-feeding women
  14. # Gagnon AJ et al. (2005) In-hospital formula supplementation of healthy breastfeeding newborns
  15. # Eidelman AI (2001) Hypoglycemia and the breastfed neonate
  16. # Gartner LM (2001) Breastfeeding and jaundice
  17. # de Carvalho M et al. (1981) Effects of water supplementation on physiological jaundice in breast-fed babies
  18. # Wegienka G et al. (2006) Breastfeeding history and childhood allergic status in a prospective birth cohort
  19. # MacIntyre EA et al. (2010) Early-life otitis media and incident atopic disease at school age in a birth cohort.
  20. # Horvath T et al. (2009) Interventions for preventing late postnatal mother-to-child transmission of HIV.
  21. # Iliff PJ et al. (2005) Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival.
  22. # Coovadia HM et al. (2007) Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study.
  23. # Smith MM et al. (2000) Exclusive breast-feeding: does it have the potential to reduce breast-feeding transmission of HIV-1?